Provider Demographics
NPI:1619684156
Name:BODDIE, JAVEONA JANEA
Entity Type:Individual
Prefix:
First Name:JAVEONA
Middle Name:JANEA
Last Name:BODDIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 LELAND AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94134-2804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 S SPRUCE AVE STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-4557
Practice Address - Country:US
Practice Address - Phone:628-946-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
101YM0800X
CA1619684156172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health